Provider Demographics
NPI:1700804135
Name:VAN WINKLE, STACI A (MD)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:A
Last Name:VAN WINKLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12730 NEW BRITTANY BLVD STE 602
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4690
Mailing Address - Country:US
Mailing Address - Phone:239-275-5522
Mailing Address - Fax:239-275-4464
Practice Address - Street 1:7381 COLLEGE PKWY STE 110
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-5527
Practice Address - Country:US
Practice Address - Phone:239-482-1010
Practice Address - Fax:239-481-1481
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME108235207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002844300Medicaid
FL149X2OtherBCBS
TN3703214Medicaid
FLDY055ZOtherMEDICARE
FL149X2OtherBCBS
TN3332588Medicare ID - Type Unspecified
TN3703214Medicaid